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Ins ection Report Number <br /> Waste Tire Sury & Inspection Report _ p p <br /> State of CaliforniaCIW <br /> Integrated 181 Waste ew 04104) <br /> California Management Board Survey Form - Page 1 5 - 10 10 <br /> ) L V <br /> Part A Survey BLUE OR BLACK INK PEN <br /> IJe' s1r�li . <br /> TPID- / j Inspection Type (Fill one) <br /> Site Suffix: r Lr s ( f <br /> ® Routine 0 Re-inspection Q Referral 0 Observation <br /> Local ! If Referral,choose referral type(Fill one) <br /> Identifier: (, (i(-`f(;�y'� ( ; (; t�.. CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> _.._ <br /> Physical Address � ��� � (�,; ( � .1( l+, 4 <br /> Street Ex <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 1 AM AM <br /> s 1, <br /> �OPM - T] : = <br /> 0PM <br /> Operational Status , ��i"°+"", Business Role <br /> � a r v[q �""� <br /> (Fill one only) � II wap i (Fill all that apply) <br /> 1�,,77 <br /> 0 Active bra,. r 'w7i° 0 Generator �+ �� f��aF ar <br /> O ^ <br /> PS Latitude 0 Closed <br /> G 0 Hauler �ta�44fS^'yf <br /> l� <br /> Mrf i7""r" w�rhut qr � <br /> 0 inactive '`,-/�� 1 �ra✓d* a riaa�w' ur" n�l h <br /> Longitude + )rira',r, 0 End-Use <br /> 9 Planned r <br /> .A A,a,yo-.' � �.r,r°�1 � �' r r >' / " �a x �/�,# a�r it 9 r �^,i.�i2 �/' a t� ,�, ,� �f'�4=!! all �k rr :�" ✓ / r fu h "?�"'r,G V r h ��' �„� <br /> BusineSS Type'""4! �' �� '" Jay '�+" G'7 "{a,r i rv,. r .' na ( ar3 ar'� r�.� a r 9 sr' �r ia;.,� "x ym rar "i" �M.�r ' ,�s .� nl r ��,C}a 1'' y reM yd d <br /> ran 'c �Ld�• "�"_,..�h �s�.�.-.._...;i, ...�...�4.Fs,,..: h,.��._4. . <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A [HAULING AID MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (Din Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> - <br /> ( <br /> Ni) N� ,s sa" m� �'a���s lea�..4�tr "r<-w�rr• � ��M�� • - - �y,( ;�,a R ty.., a., ",.�k � " {� �•. a <br /> �.�.-.� �...m ._.,.,_ <br /> IN .... ......... 62081 <br /> INSTRUCTIONS ON BACK ' Correct:: incorrect: y, d' i i I ,. 1 <br /> - "!� -� <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br /> i <br />